Provider Demographics
NPI:1619488608
Name:MANZANO MOUNTAIN COUNSELING LLC
Entity Type:Organization
Organization Name:MANZANO MOUNTAIN COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:ROSALIND
Authorized Official - Middle Name:
Authorized Official - Last Name:GUMAER
Authorized Official - Suffix:
Authorized Official - Credentials:LISW,LCSW
Authorized Official - Phone:518-755-3758
Mailing Address - Street 1:HC 66 BOX 335
Mailing Address - Street 2:
Mailing Address - City:MOUNTAINAIR
Mailing Address - State:NM
Mailing Address - Zip Code:87036-9605
Mailing Address - Country:US
Mailing Address - Phone:505-818-7881
Mailing Address - Fax:
Practice Address - Street 1:1011 ALLEN AVENUE WEST
Practice Address - Street 2:
Practice Address - City:ESTANCIA
Practice Address - State:NM
Practice Address - Zip Code:87016
Practice Address - Country:US
Practice Address - Phone:505-818-7881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-17
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-09413101YM0800X
NMI-08197101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY111575365OtherSOLUTIONS, A BRIEF THERAPY CENTER LLC
NM1861738924OtherVALENCIA COUNSELING